Febrile Convulsion Dr Minoo Saeidi Assisstant Professor of
Febrile Convulsion Dr. Minoo Saeidi Assisstant Professor of Pediatrics Isfahan University of Medical Sciences
Definition & Criteria �The single most common type of seizure seen in children between 6 months to 5 years of age �With T ≥ 38˚C �Don’t related to CNS infection �Don’t related to abnormal biochemical values �Without previous unprovoked seizure or neonatal seizure �Chance of recurrence is 12% (without any risk factor)
Etiologies �Genetics (autosomal dominant trait) �Prenatal factors (subfertility, smoking, maternal illness) �Perinatal factors (complicated first FC) �Precipitating factors (fever, HHV 6, HHV 7, shigella, pneumococcal bacteremia, DTP, 8 to 14 days after MMR, roseola, otitis media)
Risk factors associated with first FC �India � 70 febrile child with 70 child with first episode of FC between 6 mo to 5 yr �Male gender, family history of FC, peak body temperature, underlying cause of fever (URI >> UTI), antenatal complications (Hemorrhage and difficult labor), lower serum Na, lower serum Ca, lower BS, microcytic hypochromic anemia Ref: Evaluation of Risk Factors Associated with First Episode Febrile Seizure. Sharawat IK et al. J Clin Diagn Res. 2016 May
Post natal steroids and FC �Taiwan � 575 preterm (<1500 g and <32 w) �GA, ventilation day, APGAR, brain sonogram � 6% risk of FC � 14. 5% versus 3% (P= 0. 006) use of postnatal steroids �Neurodevelopmental outcome at 2 and 5 years �Steroid drugs are pro convulsive for a developing brain Ref: Postnatal Steroids and Febrile Seizure Susceptibility in Preterm Children. Tu YF et al. Pediatrics. 2016 April
Immunization and FC �Australia � 78 case of first FC � 1. 28% had recent immunization in the preceding 24 h �Another order to prescription? ? ? Ref: Prevalence of recent immunization in children with febrile convulsions. Motala L et al. World J Clin Pediatr. 2016 August
Clinical features & Categories �Simple FC �Complex FC �Status FC �Recurrent FC �Epilepsy triggered by FC
Simple FC �Generalized �Usually tonic clonic �Lasting less than 15 minute �Not recurrence in 24 h
Complex FC �Duration > 15 minutes �Recurrence within 24 h �Focal features
Status FC �Lasting 30 minutes or more �Series of seizures without full return to consciousness �Hippocampal sclerosis �T 2 finding of hippocampus on MRI �Trend to language and motor delay at one year after SFC �Race, gender, phenotype of SFC, HHV 6/7 Ref: Cognitive functioning one month and one year following febrile status epilepticus. Weiss EF et al. Epilepsy Behav. 2016 Nov
Recurrent FC �We expect only one or two recurrence generally �It may be different in type �If the patient is high risk for recurrence, we should prescribe prophylaxis with Diazepam (1 mg/Kg/day, in three divided dose) for 48 h �Clonazepam, nitrazepam, clobazam �Continuous use of Phenobarbital or Valproate ? �Antipyretic? �Screening for Iron deficiency?
Risk factors for recurrence �Major q Age < 1 year q Duration of fever < 24 h q Fever 38 -39 ˚C �Minor q Family history of FC q Family history of epilepsy q Complex FC q Male q Lower Na at presentation
Epilepsy triggered by FC �More than three episode of FC �It is not FC but it is a seizure disorder that triggered by FC �Afebrile seizure �Abnormal development �Antiepileptic drugs? �Further investigations?
Risk factors for subsequent epilepsy Risk factor Risk % Simple FC 1% Recurrent FC 4% Complex FC 6% Fever < 1 h before FC 11% Family history of epilepsy 18% Complex focal FC 29% Neurodevelopmental delay 33%
Investigations
Lumbar puncture �< 6 mo �Ill appearing child �Any age with signs or symptoms of meningitis �Optional in 6 to 12 mo according to the vaccination state and pretreatment with antibiotic �Abnormal CSF but no meningitis ?
Blood studies �Not routinely recommended in the first simple FC �Blood sugar in prolonged postictal or seizures �Signs of dehydration? �Na?
EEG �Long term outcome �Development of epilepsy �Diagnosis of acute encephalopathy �Population, timing of EEG, recording condition �Not recommended for simple FC �If it is abnormal don’t predict later epilepsy Ref: New guidelines for management of febrile seizures in Japan. Natsume J et al. Brain Dev. 2017 Jan
EEG �Focal slowing on the EEG in 72 hrs after status FC, indicate hippocampal injury �If it is indicated, do it after more than 2 wk �Nonepileptic state in status FC? �aim of EEG?
MRI or CT �Not recommended in first simple FC �Individualize in complex FC �In abnormal neurological exam �In status FC, unilateral hippocampal swelling, long term hippocampal atrophy �They go to TLE?
Treatment �Acute treatment of seizure
Treatment
Treatment �Recovery position
Treatment �Rectal diazepam
Prophylactic Diazepam �It is effective � 2/3 of children with FC don’t have another episode �Assess the risk of recurrence �Consider this treatment for children with status FC
Thank You Any Question? ? ?
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